Basic Information
| Provider Information | |||||||||
| NPI: | 1891759379 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GREENLEAF | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | THOMAS | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 190 RIVERSIDE ST | ||||||||
| Address2: | SUITE 6B | ||||||||
| City: | PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041031073 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2076612000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 96 CAMPUS DR | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | SCARBOROUGH | ||||||||
| State: | ME | ||||||||
| PostalCode: | 040747163 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078859905 | ||||||||
| FaxNumber: | 2073965600 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2006 | ||||||||
| LastUpdateDate: | 04/25/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA195 | ME | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | 001000047 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.